Revision 2 for 'Assessment of lungs, pleura and airways on chest x-ray (approach)'

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Assessment of airways, lung parenchyma, pleura on CXR

Described below are points on the systematic assessment of airways, lung parenchyma, pleura on CXR.

1. Pleura
  • pneumothorax: visceral pleural line parallel to the thoracic cavity, the absence of lung markings (vessels)
    • views to exaggerate pneumothorax: erect CXR in full expiration, lateral decubitus with the suspect side up
    • on supine film: deep sulcus sign, sharply outlined diaphragm, hyperlucent upper abdomen
    • imposters: scapula margin, clothes, wrinkles, lines/tubing, bullous disease
    • management: < 2cm - observe, > 2cm - aspirate.
  • hemo-pneumothorax: air-fluid level, no meniscus visible
  • tension pneumothorax: ipsilateral diaphragm depressed, mediastinal contents pushed contralaterally
  • pleural effusion: look for the meniscus sign. Collects in the costophrenic angles. If supine - veiling opacity. Empyema can organize into loculations
  • apical pleural thickening: focal area of thickening over the apex, can be heavily calcified
  • pleural plaques: similar to the density of bone. Common posteriorly & laterally & inferior 1/3 of the thorax. Metastasis - less dense than bone
  • lung collapse: opacity with no air bronchograms, negative mass effect (displacement of fissure, hilum, mediastinum, elevation of hemidiaphragm, the decrease in spacing between the ribs)


2. Lung parenchyma
  • lobar collapse: opacity with no air bronchogram, negative mass effect with shift of a lung fissure, hilum, hemidiaphragm
  • lung collapse: opacity with whiteout, negative mass effect with mediastinal shift to the contralateral side
  • increased interstitial marking vs. airspace opacification
  • consolidation: alveolar pathology (cloud-like/cotton-candy shadowing); no volume loss, air bronchogram, homogeneous airspace opacity. Clears by 6 weeks, if not suspect malignancy
  • pulmonary edema: interstitial opacities (too many squiggly lines); airspace opacification
  • emphysema: 1. pulmonary hyperinflation, 2. narrowed mediastinum, 3. prominant pulmonary vessels, 4. Reduced peripheral pulmonary vessels, 5. distance to hila/base


  • left ventricular failure: 1. increased interstitial marking, 2. Airspace opacification, 3. bilateral pleural effusions

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